Tobacco use is widespread among Aboriginal and Torres Strait Islander populations,1 although prevalence varies between regions and communities across Australia. The first major national study measuring smoking prevalence in the Indigenous population was the National Aboriginal and Torres Strait Islander Survey of 1994,2 subsequently updated with the National Aboriginal and Torres Strait Islander Social Surveys of 2002, 2008, and 2014–15.3–5 The National Health Surveys of 19956 and 20017 also provide data on smoking rates, and the National Aboriginal and Torres Strait Islander Health Surveys for 2004‒058 and 2012–131 have been added to this series, expanding on the Indigenous component of the earlier National Health Survey reports. As the most recent report in these series, most of the data presented in this section come from the National Aboriginal and Torres Strait Islander Social Survey, 2014–155 and the National Aboriginal and Torres Strait Islander Health Survey for 2012–13.1Data from these surveys has also been used to estimate smoking prevalence among the Stolen Generations and their descendants.9

This section includes estimates of current smoking prevalence among Aboriginal and Torres Strait Islander peoples, as well as prevalence over time. It also reports prevalence among Indigenous peoples living in remote areas and by socioeconomic indicators, as well as among pregnant women, health workers, and prison populations. Smoking rates among Indigenous populations in other countries are also reported.

8.3.1 Latest estimates of smoking prevalence

Table 8.3.1 shows the prevalence of daily smoking in 2014–15 by sex, Indigenous status, and age group. When compared to the overall Australian population, Aboriginal and Torres Strait Islander peoples have a substantially higher prevalence of smoking for all age groups among both men and women. Thirty-nine per cent of the combined Aboriginal and Torres Strait Islander population aged 15 and over were daily smokers5 compared with 14% in the general population.10 After adjusting for differences in age structure, Aboriginal and Torres Strait Islander peoples aged 15 years and over were almost three times as likely as non-Indigenous people to be daily smokers.5 Prevalence appeared to be slightly higher among Aboriginal peoples (39%) than Torres Strait Islander people (35%). There were no significant differences between Indigenous men and women in daily smoking except for 15–24 year olds and 45–54 year olds, where the prevalence among men was higher.5

Table 8.3.1
Percentage (rounded) of current daily smoking* among Aboriginal and Torres Strait Islander peoples by sex, Indigenous status and age group, 2014–15

Indigenous status

Age group

15–27

18–24

25–34

35–44

45–54

55–64

65–74

75+

Males

Indigenous

34.4

46.6

47.0

50.7

34.9

34.4^

Non-Indigenous

3.9

12.8

22.5

20.1

19.3

17.1

10.5

3.6

Females

Indigenous

26.5

44.4

46.4

41.4

28.2

26.5^

Non-Indigenous

2.3

15.1

12.1

13.4

15.5

12.4

7.0

4.5

* Current daily smokers are those who smoke one or more cigarettes (either manufactured or roll-your-own), cigars or pipes per day, on average. Chewing tobacco and smoking of substances other than tobacco are excluded.

^ The oldest age group reported in the National Aboriginal and Torres Strait Islander Social Survey was 55+

The subgroup of Aboriginal and Torres Strait Islander peoples who were born before 1972 and who have reported being removed from their families can be used as a proxy measure for the ‘Stolen Generations’ (by 1972, relevant legislation had been repealed and removal practices had ceased). In 2014-15, 50% of the Stolen Generations proxy population reported being current smokers, compared with 40% who were not removed. There was no significant difference in current smoking prevalence between the descendants of people removed (42%) and those who had not experienced any type of removal (42%).9

8.3.2 Smoking prevalence over time

There have been progressive decreases in smoking prevalence among Indigenous Australians over time. The prevalence of current (i.e., daily + less often) smoking among Indigenous adults declined by 2.4% between 1994 (the first year with reliable prevalence data) and 2004, from 54.5% in 1994 to 53.5% in 2002 to 52.1% in 2004.11 There were also declines in more recent years, from 49.8% in 2008, to 45.8% in 2012–13, to 44.5% in 2014–15.12 Figure 8.3.1 shows current smoking among Indigenous and non-Indigenous adults since 1994.

Between 2004–05 and 2014–15, the prevalence of daily smoking among Aboriginal and Torres Strait Islander adults in Australia decreased by 8.6%, from 50.0% to 41.4%. This corresponds to an estimated 35,000 fewer Aboriginal and Torres Strait Islander adult daily smokers in 2014–15, compared with if the smoking prevalence had remained stable. Declines were observed among both men and women, and were most evident among those aged 18–44 years, and those living in urban/regional areas.13

Additional encouraging data shows that between 1994 and 2014–15, smoking initiation (as indicated by smoking prevalence among Aboriginal and Torres Strait Islander peoples aged 15–17 years) also decreased. The annual decrease was faster for the period 2008 to 2014–15 than for the period 1994 to 2004–05, potentially due to the increased funding for Aboriginal and Torres Strait Islander tobacco control since 2008. The proportion of ever smokers who had quit increased among Indigenous adults from 2002 to 2014–15, with faster increases among those living in non-remote areas than in remote areas.12

There appears to have been no change to the ‘gap’ in smoking prevalence between the Aboriginal and Torres Strait Islander adult population and the non-Indigenous adult population during the 20 years to 2014–15, which remained steady at about 30 percentage points. Although there was a slower relative annual decrease in smoking prevalence among the Aboriginal and Torres Strait Islander population (1.0%) compared with the non-Indigenous population (2.7%), the average absolute annual decrease in percentage points (0.3%) was the same for both populations, and there has been substantial progress among Aboriginal and Torres Strait Islander peoples.12 Some have noted the importance of emphasising and maximising this progress, rather than focusing solely on ‘closing the gap’.13

The prevalence of current smoking among the Stolen Generation proxy population declined from about 66% in 2002 to about 50% in 2012-13.9 Compared with those who had not been removed, the Stolen Generations were more likely to be smokers in each of the survey years, with the gaps ranging from 8 to 17 percentage points. Current smoking prevalence among descendants of all people removed has also decreased over time from about 50% in 2004-05 to 42% in 2014-15.9

8.3.3 Geographical variations in smoking rates

While the figures in the above tables provide a broad overview of smoking prevalence among Aboriginal and Torres Strait Islander peoples, it is important to note that patterns of smoking are not uniform throughout Aboriginal and Torres Strait Islander communities. Although smoking prevalence among Indigenous Australians has been declining in both non-remote and remote areas, most of the change has occurred in non-remote areas. The proportion of daily smokers in non-remote areas decreased from 48% in 2002 to 37% in 2014–15, while in remote areas, there was a decrease of only three percentage points over the same period, from 50% to 47%.5 Figure 8.3.1 shows the proportion of current daily smokers by remoteness area and Indigenous status.

There are also variations in prevalence by gender within these jurisdictions. For example, in 2012–13 (National Aboriginal and Torres Strait Islander Health Survey data), daily smoking was more common among Indigenous men living in the Northern Territory (58%) and South Australia (46%) than Indigenous women in these states (44% and 35%, respectively; see ABS Table 24).1

More striking, however, are the variations in smoking behaviour between smaller regions and individual communities. The 2012–13 National Aboriginal and Torres Strait Islander Health Survey examined prevalence of smoking as defined by Aboriginal and Torres Strait Islander Commission region, and found a large variation between regions.1 For example, daily smoking prevalence ranged from 28% in the Australian Capital Territory, to 68% in Katherine. There were also marked gender differences within some regions; prevalence among Indigenous men in West Kimberley was 89%, compared with 48% among Indigenous women in the same region (see ABS Table 23).1 Other regional and community-specific surveys have also demonstrated marked differences. For example, a survey of Aboriginal and Torres Strait Islander women aged 15–34 years in 23 communities in far north Queensland found a smoking prevalence of 62%,14 and studies have confirmed higher levels of smoking in the Top End of the Northern Territory than for the Indigenous population as a whole.15-18 The most recent of these studies found smoking prevalence of 76%17 and 70%18 in Top End communities.

Readers interested in examining earlier regional prevalence surveys are referred in the first instance to the comprehensive literature review by Ivers,19 which provides a summary of research up until 1999.

8.3.4 Socio-economic factors

Socio-economic factors are strongly related to smoking behaviour throughout the general Australian population (see Chapter 1, Section 1.5 for further discussion).

Aboriginal and Torres Strait Islander peoples are still significantly more likely than non-Indigenous people to be disadvantaged, in measures such as educational attainment, employment, income, and home ownership.4,20 In 2014–15, 61% of Indigenous Australians of working age (15– 64 years) were in the labour force; compared with 77% of non-Indigenous Australians. The proportion of Indigenous Australians of working age who were not in the labour force increased from 36% in 2008 to 39% in 2014–15.21 Indigenous Australians have relatively low average weekly incomes compared with non-Indigenous people and are under-represented in the highest income bracket. In 2014–15, more than one-third (36%) of Indigenous adults were living in households in the lowest income quintile; twice the proportion of non-Indigenous adults (17%).21Moreover, Aboriginal and Torres Strait Islander peoples are over-represented among those Australians who experience mental illness (as evidenced by self-reported levels of psychological distress, depression, higher rates of hospitalisation for mental illness, and death and injury through suicide and intentional injury), homelessness, and exposure to the criminal justice system as offenders (with imprisonment at 13 times the rate of non-Indigenous people and juvenile detention at 23 times the rate for non-Indigenous youth).22 Each of these factors is associated with a greater likelihood of smoking (see Chapter 1, Section 1.8). The overall higher degree of disadvantage experienced by Aboriginal and Torres Strait Islander peoples is likely to be a major contributor to the high prevalence of smoking.

The prevalence of smoking also varies within the Aboriginal and Torres Strait Islander populations according to socio-economic factors, as they do in the general Australian population. Smoking is more prevalent among Aboriginal and Torres Strait Islander peoples who have less education, are unemployed, are renting rather than owning or buying their own home, and who are in the lower income brackets.23–25 Table 8.3.3 presents findings for the 2012–13 National Aboriginal and Torres Strait Islander Health Survey, with data for the non-Indigenous population from the 2011–12 Australian Health Survey included for comparison. When comparing Indigenous and non-Indigenous people of similar socio-economic status, Indigenous people have a higher smoking prevalence than for non-Indigenous people.

Table 8.3.2
Age-standardised proportion of current daily smoking among Aboriginal and Torres Strait Islander peoples (2012–13) and the non-Indigenous population (2011–12) aged 18 and over by a range of socio-economic indicators

Current daily smokers

(% rounded)

Age-standardised rate ratio*

Indigenous people

Non-Indigenous people

Persons aged 18 years and over

42

16

2.6

Highest year of school completed†

Year 12

28

11

2.6

Year 11

44

21

2.1

Year 10 or below

49

29

1.7

Labour force status

Employed

35

16

2.2

Unemployed

56

28

1.7

Not in the workforce

48

19

2.5

* Indigenous to non-Indigenous rate ratios are calculated by dividing the proportion of Indigenous people with a particular characteristic by the proportion of non-Indigenous people with the same characteristic.

Experiencing more than one life stressor (for example, serious illness, death of a family member or friend, divorce, alcohol or drug-related problems, abuse, overcrowding, discrimination or racism) and feeling financial stress in the previous year (defined as lacking the ability for themselves or another household member to access $2000 in an emergency) were also indicators for increased risk of smoking in Indigenous adults in the 2002 and the 2004–05 national Aboriginal and Torres Strait Islander surveys.24,25 The 2004–05 survey also reported significant associations between smoking and higher levels of psychological distress or having a disability or other long-term health condition.25 Data from the 2002 National Aboriginal and Torres Strait Islander Social Survey show that Aboriginal and Torres Strait Islander peoples who had been arrested or incarcerated in the last five years were significantly more likely to be smokers; those who reported all four of ‘arrested in last 5 years’, ‘incarcerated in last 5 years’, ‘used legal services in past 12 months’ and ‘victim of violence in past 12 months’ were nearly 10 times more likely to be smokers than those who did not report any of these experiences.24

Although Aboriginal and Torres Strait Islander communities have had different experiences of colonisation, the colonising process has overall had an important influence on ongoing patterns of tobacco use by Aboriginal and Torres Strait Islander peoples (see Section 8.2). Detailed analyses of the 1994 National Aboriginal and Torres Strait Islander Survey and the 2002 National Aboriginal and Torres Strait Islander Social Survey identify removal from family as significantly related to being a smoker.23,24 After adjusting for age, gender and socio-economic variables, the 2002 Social Survey data showed that Aboriginal and Torres Strait Islander people were twice as likely to be smokers if they had been removed from their natural family.24

There is a significant association between racism and smoking.27 A study of pregnant Indigenous women in Perth reported that stress related to racial discrimination was a factor contributing to their smoking.28

8.3.5 Prevalence of smoking among pregnant women

In 2016, Indigenous mothers accounted for 20% of mothers who smoked tobacco at any time during pregnancy, despite accounting for only around 4% of mothers. About 2 in 5 of Indigenous mothers reported smoking during pregnancy—43% compared with 12% of non-Indigenous mothers (age-standardised). The proportion of Indigenous mothers who smoked during pregnancy decreased from 50% in 2009 to 43% in 2016.29 Several local or regional studies have also shown that Indigenous women have a higher prevalence of smoking during pregnancy and after giving birth than non-Indigenous women, with reported smoking prevalence ranging from 41‒67%.30-37 An analysis of the 2007 National Perinatal Data Collection shows that smoking rates for Indigenous mothers was highest for those in outer regional areas (56%) and lowest for those in major cities (49.3%).38

In 2015, one quarter of teenage mothers identified as Aboriginal and/or Torres Strait Islander, while comprising only 5% of the female population in the same age group. Compared to non-Indigenous teenage mothers, Indigenous teenage mothers were 1.5 times as likely to smoke in the first 20 weeks of pregnancy (43% compared with 28%) and 1.7 times as likely to smoke after 20 weeks (36% compared with 21%).39This trend of higher smoking rates during pregnancy among teenage Indigenous women has also been found in studies in Queensland, South Australia and Western Australia.32,40,41 The South Australian study also reported that the likelihood of smoking heavily (consuming 20 or more cigarettes daily) increased with age, and at all ages except for during their teens, Indigenous women smoked more heavily during pregnancy than non-Indigenous women.40

8.3.6 Prevalence of smoking among health workers

A range of small surveys42–48 and anecdotal evidence49 suggest that Aboriginal and Torres Strait Islander health workers have a high prevalence of smoking. Findings have ranged between 38% and 51%,42,44–46,48 and about 60–64%.>43,47 One survey, undertaken as part of the National Aboriginal and Torres Strait Islander Tobacco Control Project, found that 39% of health workers who participated in focus groups for the project were smokers. Lindorff observed that this was likely to be an underestimate of actual smoking rates among health workers, since smokers were noticeably less likely to volunteer to participate.42 Research has found that many Indigenous health workers who smoke, smoke heavily,45 and that tobacco use provides a means of coping with the stressful nature of their workloads.45,47 A 2013 study of Aboriginal health workers in South Australia found that the prevalence of current smokers was 50.6%; non-smokers (49.5%) comprised quitters (22.4%) and never smokers (27.1%).48 Surveys of staff of Aboriginal community-controlled health services in 2012–13 found that smoking prevalence among Aboriginal and Torres Strait Islander staff was lower than their general communities, but only modestly lower than among other employed Aboriginal and Torres Strait Islander people.50 These studies indicate a need for appropriate support and education for health workers as well as the communities in which they work. See Section 8.10.5 for further information on the role of Indigenous health workers in tobacco control, and Section 8.13.5 on policy and funding initiatives to support the health workforce in Aboriginal and Torres Strait Islander health.

8.3.7 Prevalence of smoking among prison populations

Smoking rates among prisoners are generally much higher than in the general community,51 and Aboriginal and Torres Strait Islander peoples are significantly overrepresented in the prison population. Between 2006 and 2016, the Indigenous imprisonment rate increased by 53%, and in 2016 the Indigenous imprisonment rate was 13 times the non-Indigenous rate.21The 2015 Australian Institute of Health and Welfare report on the health of Australia’s prisoners found that Indigenous peoples were more likely than non-Indigenous people to be current smokers upon entry to prison (82% and 72% respectively); however, similar proportions of Indigenous and non-Indigenous dischargees reported being current smokers, and Indigenous dischargees were more likely to have decreased their smoking (45% compared with 38% of non-Indigenous), particularly in prisons with complete smoking bans (smoking bans have been or are being implemented in prisons in all Australian states and territories except Western Australia). More than half (54%) of Indigenous prison entrants who smoked reported that they would like to quit, although most did not access the available cessation assistance.52

Smoking cessation programs for Indigenous prisoners, and the more recent implementation of total prison smoking bans, are discussed in Section 8.10.13.4.

8.3.8 International comparisons with other Indigenous peoples

International research has shown that Indigenous groups in settler colonial countries use tobacco at significantly higher levels than the dominant population (Table 8.3.4). Notwithstanding the differences between these populations and their specific cultural and historical circumstances, it is likely that these higher prevalence figures also reflect socio-economic disadvantage, and the legacy of colonisation including experiences of marginalisation, family dislocation, racism, disconnection from land, loss of traditional diet and lifestyle, and the subsequent adoption and adaption of Western habits and practices.53

Table 8.3.4
Prevalence rates of current smokers for Indigenous and non-Indigenous people in Canada, New Zealand, the United States and Australia

11.Thomas D. Smoking prevalence trends in Indigenous Australians, 1994−2004: A typical rather than an exceptional epidemic. International Journal for Equity in Health, 2009; 8(1):37. Available from: http://www.equityhealthj.com/content/8/1/37

15.Hoy W, Norman R, Hayhurst B, and Pugsley D. Health profile of adults in a Northern Territory Aboriginal community, with an emphasis on preventable morbidities. Australian and New Zealand Journal of Public Health, 1997; 21(2):121−6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9161065

20.Australian Bureau of Statistics and Australian Institute of Health and Welfare. 4704.0. The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples, 2010 Canberra: ABS, 2010. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/mf/4704.0.

24.Thomas DP, Briggs V, Anderson IP, and Cunningham J. The social determinants of being an Indigenous non-smoker. Australian and New Zealand Journal of Public Health, 2008; 32(2):110–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18412679

40.Chan A, Keane R, and Robinson J. The contribution of maternal smoking to preterm birth, small for gestational age and low birthweight among Aboriginal and non-Aboriginal births in South Australia. Medical Journal of Australia, 2001; 174(8):389–93. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11346081

42.Lindorff KJ. Tobacco time for action: National Aboriginal and Torres Strait Islander tobacco control project final report. Canberra, Australia: National Aboriginal Community Controlled Organisations, 2002.

43.Andrews B, Oates F, and Naden P. Smoking among Aboriginal health workers: Findings of a 1995 survey in western New South Wales. Australian and New Zealand Journal of Public Health, 1997; 21:789–90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9489201

45.Kerdel K and Brice G. Exploring the smokescreen—reducing the stress: Action research on tobacco with Aboriginal primary health care workers in Adelaide. Adelaide: Aboriginal Health Council of South Australia, 2001.